International consensus-based policy recommendations to advance universal palliative care access from the American Academy of Nursing Expert Panels.

The purpose of this consensus paper was to convene leaders and scholars from eight Expert Panels of the American Academy of Nursing and provide recommendations to advance nursing's roles and responsibility to ensure universal access to palliative care. On behalf of the Academy, these evidence-based recommendations will guide nurses, policy makers, government representatives, professional associations, and interdisciplinary and community partners to integrate palliative nursing services across health and social care settings. Through improved palliative nursing education, nurse-led research, nurse engagement in policy making, enhanced intersectoral partnerships with nursing, and an increased profile and visibility of palliative care nurses worldwide, nurses can assume leading roles in delivering high-quality palliative care globally, particularly for minoritized, marginalized, and other at-risk populations. Part II herein provides a summary of international responses and policy options that have sought to enhance universal palliative care and palliative nursing access to date. Additionally, we provide ten policy, education, research, and clinical practice recommendations based on the rationale and background information found in Part I. The consensus paper's 43 authors represent eight countries (Australia, Canada, England, Kenya, Lebanon, Liberia, South Africa, United States of America) and extensive international health experience, thus providing a global context for the subject matter.

American Academy of Nursing Expert Panel consensus statement on nursing's roles in ensuring universal palliative care access.

The purpose of this consensus paper was to convene leaders and scholars from eight Expert Panels of the American Academy of Nursing and provide recommendations to advance nursing's roles and responsibility to ensure universal access to palliative care. Part I of this consensus paper herein provides the rationale and background to support the policy, education, research, and clinical practice recommendations put forward in Part II. On behalf of the Academy, the evidence-based recommendations will guide nurses, policy makers, government representatives, professional associations, and interdisciplinary and community partners to integrate palliative nursing services across health and social care settings. The consensus paper's 43 authors represent eight countries (Australia, Canada, England, Kenya, Lebanon, Liberia, South Africa, United States of America) and extensive international health experience, thus providing a global context for the subject matter. The authors recommend greater investments in palliative nursing education and nurse-led research, nurse engagement in policy making, enhanced intersectoral partnerships with nursing, and an increased profile and visibility of palliative nurses worldwide. By enacting these recommendations, nurses working in all settings can assume leading roles in delivering high-quality palliative care globally, particularly for minoritized, marginalized, and other at-risk populations.

Applying Supervised Machine Learning to Identify Which Patient Characteristics Identify the Highest Rates of Mortality Post-Interhospital Transfer.

OBJECTIVE: To demonstrate the usefulness of applying supervised machine-learning analyses to identify specific groups of patients that experience high levels of mortality post-interhospital transfer. METHODS: This was a cross-sectional analysis of data from the Health Care Utilization Project 2013 National Inpatient Sample, that applied supervised machine-learning approaches that included (1) classification and regression tree to identify mutually exclusive groups of patients and their associated characteristics of those experiencing the highest levels of mortality and (2) random forest to identify the relative importance of each characteristic's contribution to post-transfer mortality. RESULTS: A total of 21 independent groups of patients were identified, with 13 of those groups exhibiting at least double the national average rate of mortality post-transfer. Patient characteristics identified as influencing post-transfer mortality the most included: diagnosis of a circulatory disorder, comorbidity of coagulopathy, diagnosis of cancer, and age. CONCLUSIONS: Employing supervised machine-learning analyses enabled the computational feasibility to assess all potential combinations of available patient characteristics to identify groups of patients experiencing the highest rates of mortality post-interhospital transfer, providing potentially useful data to support developing clinical decision support systems in future work.

High-Risk Comorbidity Combinations in Older Patients Undergoing Emergency General Surgery.

BACKGROUND/OBJECTIVES: Over a million older patients in the United States are admitted yearly for emergency general surgery (EGS) conditions. Seven procedure types dominate: colon, small bowel, gallbladder, ulcer disease, adhesiolysis, appendix, and laparotomy operations. A higher comorbidity burden is known to increase mortality in this population, but the impact of specific comorbidity combinations is unknown. Our objectives were to (1) characterize the distribution of procedures, comorbidities, and outcomes for older patients undergoing EGS; and (2) apply a data-driven approach (association rule mining) to identify comorbidity combinations associated with disproportionately high mortality. DESIGN, SETTING, AND PARTICIPANTS: Cross-sectional study of patients 65 years and older who underwent one of the seven procedures previously cited, taken from the 2011 Nationwide Inpatient Sample. A total of 280 885 patient encounters were identified. MEASUREMENTS: In-hospital mortality, procedures, and comorbidities based on the Elixhauser Comorbidity Index. RESULTS: Overall mortality was 5.6%. The most common procedures were gallbladder (33.7%), ulcer surgery (21.5%), and adhesiolysis (21.0%). Mortality increased for all procedures as patients aged. Comorbidities associated with the highest mortality included coagulopathy (adjusted odds ratio [aOR] = 3.74; 95% confidence interval [CI] = 3.41-4.11; p < .001), fluid and electrolyte disorders (FED) (aOR = 2.89; 95% CI = 3.66-3.14; p < .001), and liver disease (aOR = 1.89; 95% CI = 1.61-2.22; p < .001). Three-way comorbidity combinations most highly associated with mortality were coagulopathy, FED, and peripheral vascular disease (aOR = 5.10; 95% CI = 4.17-6.24; p < .001), and coagulopathy, FED, and chronic pulmonary disease (aOR = 4.83; 95% CI = 4.00-5.82; p < .001). CONCLUSION: For older patients, combinations of comorbidities portend additional risk beyond single comorbidities, and the associated risk burden is driven by the specific constellation of comorbidities present. Future work must continue to examine the effect of co-occurring diseases to provide personalized and realistic prognostication for older patients undergoing EGS. J Am Geriatr Soc 67:503-510, 2019.

Psychiatric disease in surgically treated colorectal cancer patients.

BACKGROUND: Underlying psychiatric conditions may affect outcomes of surgical treatment for colorectal cancer (CRC) because of complex clinical presentation and treatment considerations. We hypothesized that patients with psychiatric illness (PSYCH) would have evidence of advanced disease at presentation, as manifested by higher rates of colorectal surgery performed in the presence of obstruction, perforation, and/or peritonitis (OPP-surgery). MATERIALS AND METHODS: Using data from the 2007-2011 National Inpatient Sample, we identified patients with a diagnosis of CRC undergoing colorectal surgery. In addition to somatic comorbid conditions flagged in the National Inpatient Sample, we used the Clinical Classification Software to identify patients with PSYCH, including schizophrenia, delirium/dementia, developmental disorders, alcohol/substance abuse, and other psychiatric conditions. Our study outcome was OPP-surgery. In addition to descriptive analysis, we conducted multivariable logistic regression analysis to analyze the independent association between each of the PSYCH conditions and OPP-surgery, after adjusting for patient demographics and somatic comorbidities. RESULTS: Our study population included 591,561 patients with CRC and undergoing colorectal cancer surgery, of whom 60.6% were aged 65 years or older, 49.4% were women, and 6.3% had five or more comorbid conditions. Then, 17.9% presented with PSYCH. The percent of patients undergoing OPP-surgery was 13.9% in the study population but was significantly higher for patients with schizophrenia (19.3%), delirium and dementia (18.5%), developmental disorders (19.7%), and alcohol/substance abuse (19.5%). In multivariable analysis, schizophrenia, delirium/dementia, and alcohol/substance abuse were each independently associated with increased rates of OPP-surgery. CONCLUSIONS: Patients with PSYCH may have obstacles in receiving optimal care for CRC. Those with PSYCH diagnoses had significantly higher rates of OPP-surgery. Additional evaluation is required to further characterize the clinical implications of advanced disease presentation for patients with PSYCH diagnoses and colorectal cancer.

Using Text Reminder to Improve Childhood Immunization Adherence in the Philippines.

A comparative descriptive study was conducted to determine the effectiveness of text messages with pictures compared with plain text messages or verbal reminders in improving measles, mumps, and rubella immunization compliance in the rural areas of the Philippines. We found that text messaging with or without pictures is a feasible and useful tool in measles, mumps, rubella immunization compliance for childhood immunization. Texting with pictures (n = 23), however, was no more effective than plain text messaging (n = 19) or verbal reminder (n = 17) in improving measles, mumps, and rubella immunization compliance. Compared with parents who received verbal reminders alone, either type of text reminders was linked to parents bringing their child for measles, mumps, and rubella immunization on a timelier basis, as defined by the difference between the scheduled visit and the actual visit, although this was not statistically significant. Mobile technology that uses text reminders for immunization can potentially improve the communication process between parent, the public health nurse, and healthcare provider. Future studies can explore the application of plain text messages or text messages with pictures to improve compliance more broadly for maternal and child healthcare especially in rural areas of developing countries and may be a helpful tool for health promotion for this population.

A description of adverse events in home healthcare.

Patient safety has taken on increasing importance in the American healthcare system, yet there is little information on patient safety in home healthcare. The current study aimed to describe the most frequent adverse events defined by the Centers for Medicare & Medicaid Services among the national population of patients receiving home healthcare in 2003, and to compare characteristics between patients who experience adverse events and those who do not. The findings show that 13% of all home healthcare patients had an adverse event, with 80% experiencing only 1 adverse event. More than three fourths of the adverse events were associated with discharge to the community and required continued assistance. Patients who experienced adverse events were older, had more depressive symptoms and behavioral problems, and were more functionally impaired. Women had a slightly lower relative risk of an adverse event (.98), whereas patients of minority ethnicity had a slightly higher relative risk (1.06). These findings suggest that home healthcare agencies may need to spend more time on discharge planning after home healthcare and work with existing community providers. The findings also raise questions regarding the appropriateness of these adverse events and whether there are additional adverse events that warrant monitoring and follow-up evaluation.

Data, information, and quality indicators for home healthcare: rapid implementation, what's next?

From 1999 to 2003, the home health industry in the United States moved from an environment with extremely diverse data collection protocols and little or no dissemination of quality-related information, to an environment in which uniformly collected clinical data are transformed into information and then into publicly available reports using federally mandated quality indicators. This speed to action has raised many questions about the adequacy of home healthcare data and their use as quality-monitoring tools. This article summarizes current evidence about the scientific and clinical adequacy of data currently used to measure home healthcare quality and discusses roles of a variety of policy stakeholders in implementing and refining data, information, and quality indicators that are now the cornerstones of federal home healthcare quality policy. The scientific adequacy of Outcome and Assessment Information Set data is acceptable but bears routine monitoring and review; efforts should be made to develop home healthcare quality indicators sensitive to nursing interventions and published clinical practice guidelines for specific medical conditions; and policy stakeholders should collaborate to maximize the utility of home healthcare quality reports now disseminated to consumers, providers, and insurers.